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DDuring an inspection of a nursing home in Ogden last year, state regulators found three residents who were in "immediate jeopardy."

One resident at Mountain View Health Services who needed a feeding tube was fed while he was lying down. Food had entered his airway in the past but he continued to be fed in that position. He had developed aspiration pneumonias five times and became bed-bound. Inspectors reviewed medical notes and could see no evidence that the facility had tried to prevent the problems, and they personally witnessed improper feedings five times.

Two other residents were found to have fallen dozens of times — one fell 49 times in a year, with a handful resulting in serious injuries including a skull fracture — but the facility hadn't made changes to prevent further tumbles, according to the inspection report.

Those are two of some of the most serious deficiencies cited at eight of Utah's 88 nursing homes. At least one, Orem Rehabilitation and Nursing Center, was cited in a death, after staff members failed to use a suction machine to clear a patient's airway.

The reports are available on the Nursing Home Inspect tool created by the nonprofit news organization ProPublica. The investigative newsroom took publicly available inspection reports and created an app that makes them more user-friendly, with state-specific pages listing nursing homes and their inspection reports. It also linked the reports to federal fines and other sanctions taken against the homes, revealing wide disparities between states.

The app, available to the public at, shows Utah nursing homes have some of the fewest serious deficiencies per home. The state also has some of the country's lowest average fines, at $2,500 compared to the highest in Washington at $90,000, and one of the lowest number of payment suspensions. That is when the federal Centers for Medicaid and Medicare (CMS) refuses to pay for new patient admissions.

Utah had two payment suspensions in the past three years, compared to Texas' 198.

The Utah Department of Health, which inspects the homes for CMS, said it wasn't keeping fines low. It follows guidelines on civil-penalty amounts issued by the regional CMS office, said Greg Bateman, manager of long-term care surveys.

CMS can overrule what local inspectors suggest, he said. Within the six-state region, Utah is one of two states that levied fines. Montana, North Dakota, South Dakota and Wyoming didn't, according to the ProPublica data.

Utah's two payment suspensions took place at Deseret Care Center, Salt Lake City, and Four Corners Regional Care Center, Blanding, both this past summer.

Inspection reports note that Four Corners didn't notify two patients' physicians when they were injured, and it didn't assess a patient who complained of abdominal pain. The patient later insisted on going to the hospital. Another patient wasn't sent to the hospital after complaining about rib pain.

Deseret Care was faulted for 27 deficiencies this summer, including dirty conditions such as rooms that strongly smelled of urine, not cleaning a resident who had been incontinent, leaving patients in pain or confusion because the facility didn't have their prescribed medication, and not investigating an incident in which a resident called another resident the "N-word" and hit her with his walker.

The website allows users to find facilities with the highest and lowest number of deficiencies and fines.

Mountain View Health had Utah's highest number of total deficiencies, at 101, and highest number of serious ones — in which residents are in immediate jeopardy — at four. It has also been fined the most amount, nearly $28,000.

"It caught us all completely off guard," Mountain View administrator Reece Nelson said of the poor inspection. "It wasn't really an accurate picture of what this facility is all about."

He said the facility improved its system for preventing falls and trained employees on feeding patients who use a gastrostomy tube.

"Our focus," he said, "certainly is the safety and the care of our residents." —

Citations in Utah

These Utah nursing homes were cited for serious deficiencies, according to three years of data compiled by ProPublica.

Patient death

Orem Rehabilitation and Nursing Center was cited Sept. 12, 2011, in connection with a patient death, for not providing necessary care.

The patient, who struggled to breathe and couldn't swallow, was fed a drink and solid food. When her breathing worsened, no CPR was performed because she had a Do Not Resuscitate order, and she died.

However, staff were supposed to use suction for her medical condition, which was not disclosed. Staff later said they didn't know where the facilities' emergency equipment was located or if it included a suction machine. The director of nursing later said she had not done any emergency-preparedness training with the staff in the past year she was there.

Patient injuries and risks

Aspen Ridge Transitional Rehab, Murray, cited Sept. 22, 2010,for not preventing avoidable accidents. Hand-sink temperatures were as high as 146.5 F.

Canyon Rim Care Center, Salt Lake City, cited June 21 for not preventing avoidable accidents. Windows in two rooms on the third floor opened the full length but should only open six inches.

Deseret Care Center, Salt Lake City, cited July 15, 2010, for not preventing avoidable accidents. Hand-sink temperatures were as high as 140 degrees.

Provo Rehabilitation and Nursing, cited Feb. 2for not keeping residents safe from serious medication errors. Patients were given more insulin than ordered by their physicians.

Rocky Mountain Care, Murray, cited Aug. 19, 2009, for not protecting residents from abuse. Staff members used physical force to bring a resident into the building, place him in bed and take his wheelchair against his will.

Thatcher Brook Rehabilitation and Care, Clearfield, cited July 6, 2010, for not preventing avoidable accidents. Hand-sink temperatures were as high as 125. A patient had complained, but no action was taken.

Source: ProPublica